the measurement and monitoring of safety charles vincent health foundation professor of psychology...
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The Measurement and Monitoring of Safety
Charles VincentHealth Foundation Professor of Psychology
University of Oxford
Susan Burnett
Jane Carthey
10% patients harmed, half
judged preventable
UK National Reporting & Learning System
Hospital Episode Statistics: 11.8M hospital admissions in England 2004/5
But incident reporting only detects 5% of
harmful events
We do not know whether we are making progress or not
Just tell me - are we safe?
Commissioning. How do we know care is safe?
• Tools and approaches to measuring safety
• Provide a future direction
• Jane Jones, Jonathan Bamber
Methods
Reviews of research literature and reports from organisations:
– Safety relevant industries – Conceptual approaches and models of systems safety– Measurement and monitoring in healthcare– The role of patients and families
Interviews with senior staff in national organisations Case studies in healthcare organisations in the UK
and USA across sectors
Safety in high risk industries
Lagging indicators– Measures of events of incidents– Reactive measures safety performance– Lost time injuries, incident reporting, thoroughness of
incident investigation Leading indicators
– Precursors, events or measures that purportedly predict safety performance
– Monitoring of key control systems or actions– Safety management system audits, safety cases, culture
surveys and walk rounds
Safety in NHS
High Risk Industries
Models of Safety
?
The fundamental questions
Has patient care been safe in the past? Are our clinical systems and processes reliable? Is care safe today? Will care be safe in the future? Are we responding and improving?
Safety in NHS
High Risk Industries
Models of Safety
Case Studies
Has patient care been safe in the past?
Are our clinical systems and processes reliable?
Is care safe today? Will care be safe in the future?
Are we responding and improving?
What do we mean by harm?
Treatment specific harm Harm due to over treatment General harm from healthcare Harm due to failure to provide appropriate
treatment Harm due to failed or inadequate diagnosis Psychological harm and feeling unsafe Harm due to neglect and dehumanisation
Adverse events in older people • Errors, omissions• Operative/procedural complications• Hospital acquired infections• Adverse drug events
Adverse events affecting all age groups
Adverse events affecting all age groups
Adverse events in older people • Errors, omissions• Operative/procedural complications• Hospital acquired infections• Adverse drug events
Adverse events affecting all age groups
Adverse events affecting all age groups
• Falls• Pressure sores• Incontinence• Functional ± mobility decline• Delirium• Depression• Nutritional decline• Dehydration
The geriatric syndromes
The geriatric syndromes
Should be thought of as adverse events•Preventable?•Prolonged hospital stay•Increased morbidity and mortality
Should be thought of as adverse events•Preventable?•Prolonged hospital stay•Increased morbidity and mortality
+
Are our clinical systems and processes reliable?
• Measuring and testing reliability: the WISER study –– Clinical information availability at the point of decision
making
– Prescribing for hospital inpatients
– Equipment in theatres
– Equipment for inserting IV lines
– Handover between wards
Reliability of equipment availability in operating theatres
Missing & faulty equipment
SiteTotal
operations studied
Number of operations with
equipment problems
Number of equipment problems
Percentage operations with one or more
equipment problems
A 258 50 56 19%
D 67 25 28 37%
F 165 19 19 12%
Total 490 94 103 19%
‘We always need a colposcope with that
list and time and time again it isn’t there
or it’s broken or it isn’t back or nobody
knows where it is’
Surgeon 3 Organisation A
Sensitivity to operations
Clinicians monitor their patients, watching for subtle signs of deterioration or improvement,
Leaders monitor their teams for signs of discord, fatigue or lapses in standards.
Managers have to be alert to the impact of staff shortages, equipment breakdowns, sudden increases in patient flow and other problems.
Soft intelligence
Safety walk-rounds Using designated patient safety officers Operational meetings, handovers and ward rounds Briefings and debriefings Day to day conversations And above all …. the patient voice
Anticipation and Preparedness:Will care be safe in the future?
WHO Surgery Checklist Risk assessments
– (falls, pressure ulcers, self harm) Risk registers Safety culture assessments Safety cases
Bringing available information in the organisation to anticipate safety in the future
Possibilities for quantitative prediction
Hospitals with low nurse staffing levels tend to have higher rates of pneumonia, shock, cardiac arrest, and urinary tract infections (AHRQ 2004)
Adjusted risk of death was higher if the procedures were carried out on Friday (+ 44%) or a weekend (+ 82%) compared with Monday.
Integration & learning. Are we responding and improving?
Berwick Report
“Most Health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed and that early warning signals can be valued and should be maintained and heeded” (Berwick, 2013, p26)
Great Ormond St: team level
Number of days since the last serious incident (SI)– narrative, lessons learnt and recommendations
Central venous line, MRSA (MSSA) infection rates Hand hygiene compliance rate WHO Surgical Safety Checklist compliance rate per
clinical unit Common themes identified in executive walk-rounds Medication errors Top three risks from the clinical unit’s risk register.
Intermountain Healthcare
Online reports portal with 80 quality and patient safety metrics patient safety metrics
Use of electronic records and data provided by care provider as part of clinical workflow
Web-enabled reporting and SPC charts on demand including:
– Centres for Medicare and Medicaid Services (CMS)– The Joint Commission core measures, – Quality Forum (NQF) etc. Intermountain captures
patient harm from existing
Response & Evolution
Reflections on the framework & the report
Does it seem like you always knew it? – Even though it was not explicit and we didn’t act on it
‘Deceptively simple’ or even ‘elegantly simple’?– But very different from current approaches
Expanding our vision Structuring our thinking The proof of the framework will be in the
expansion, validation & application
Information should include the perspective of patients and their families; measures of harm;
measures of the reliability of critical safety processes; on practices that encourage the monitoring of safety;
on the capacity to anticipate safety problems; on the capacity to respond and learn from safety information.
Assurance Inquiry
Are we safe?
What can we learn about safety today?